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Table 6 Description of the final set of indicators

From: Development of type 2 diabetes mellitus quality indicators in general practice by a modified Delphi method in Beijing, China

Categories Indicators Description Measurement Data source
1. Access 1.1 Personal doctor GP is the personal doctor providing continuous care for T2DM patient The percentage of T2DM patients who recognize that they are being managed by a personal doctor Patient survey
1.2 GP team Patient is being managed by a functioning GP team (a GP, nurse, and preventive care physician) The percentage of T2DM patients who recognize that they are being managed by a functioning GP team Patient survey
1.3 Waiting time Waiting time for consultation is reasonable for the patient The percentage of T2DM patients who recognize that the waiting time for consultation is reasonable Patient survey
1.4 Health advice Seeking health advice from the GP team is convenient for the patient The percentage of T2DM patients who recognize that it is convenient to seek health advice from the GP team Patient survey
1.5 Referral access Patient has ensured referral access to necessary specialist care The percentage of T2DM patients who recognize that referral access to necessary specialist care is ensured Patient survey
2. Monitoring 2.1 Regular follow up At least 4 times of follow up by the GP team in the audit year The percentage of T2DM patients who are followed up for at least 4 times by the GP team in the audit year EHR
2.2 Plasma blood glucose monitoring At least 4 measurements of plasma blood glucose test (fasting or post-prandial) by the GP team in the audit year The percentage of T2DM patients who have at least 4 measurements of plasma blood glucose test (fasting or post-prandial) by the GP team in the audit year EHR
2.3 HbA1c monitoring At least 2 measurements of HbA1c test in the audit year The percentage of T2DM patients who have at least 2 measurements of HbA1c test in the audit year EHR
2.4 BP monitoring At least 4 measurements of BP by the GP team in the audit year The percentage of T2DM patients who have at least 4 measurements of BP by the GP team in the audit year EHR
2.5 Lipid monitoring At least 1 measurement of lipid test in the audit year The percentage of T2DM patients who have at least 1 measurement of lipid test in the audit year
Tests: TC, TG, LDL-C, HDL-C
EHR
2.6 BMI monitoring At least 1 measurement of BMI in the audit year The percentage of T2DM patients who have at least 1 measurement of BMI in the audit year EHR
2.7 Waist circumference monitoring At least 1 measurement of waist circumference in the audit year The percentage of T2DM patients who have at least 1 measurement of waist circumference in the audit year EHR
2.8 ECG monitoring At least 1 measurement of ECG in the audit year The percentage of T2DM patients who have at least 1 measurement of ECG in the audit year EHR
2.9 Nephropathy monitoring At least 1 nephropathy examination in the audit year The percentage of T2DM patients who have at least 1 nephropathy examination in the audit year
Tests: creatinine, blood urea nitrogen, urine protein
EHR
2.10 Retinopathy monitoring At least 1 retinopathy examination in the audit year The percentage of T2DM patients who have at least 1 retinopathy examination in the audit year
Tests: vision, funduscope or fundus photography
EHR
2.11 Peripheral neuropathy monitoring At least 1 peripheral neuropathy examination in the audit year The percentage of T2DM patients who have at least 1 peripheral neuropathy examination in the audit year
Tests: temperature, pinprick sensation and vibration sensation, 10-g monofilament testing
EHR
2.12 Foot monitoring At least 1 diabetic foot examination in the audit year The percentage of T2DM patients who have at least 1 diabetic foot examination in the audit year
Tests: Skin inspection, pulse palpation
EHR
3. Health counseling 3.1 Diet counseling Diet counseling is provided for the patient in the audit year The percentage of T2DM patients who are provided with diet counseling in the audit year Patient survey
3.2 Exercise counseling Exercise counseling is provided for the patient in the audit year The percentage of T2DM patients who are provided with exercise counseling in the audit year Patient survey
3.3 Psychological assessment or counseling Psychological assessment is provided for the patient or referral to professional counseling when necessary in the audit year The percentage of T2DM patients who are provided with psychological assessment or referral to professional counseling when necessary in the audit year Patient survey
3.4 Smoking assessment or counseling Smoking assessment is provided for the patient or referral to professional counseling when necessary in the audit year The percentage of T2DM patients who are provided with smoking assessment or referral to professional counseling when necessary in the audit year Patient survey
3.5 Hypoglycemia awareness counseling Hypoglycemia awareness counseling is provided for the patient in the audit year The percentage of T2DM patients who are provided with hypoglycemia awareness counseling in the audit year Patient survey
3.6 Medication safety counseling Medication safety counseling is provided for the patient in the audit year The percentage of T2DM patients who are provided with medication safety counseling in the audit year Patient survey
3.7 Emergency help counseling Emergency help counseling is provided for the patient to improve the patient’s knowledge on seeking emergency help in the audit year The percentage of T2DM patients who are provided with emergency help counseling in the audit year Patient survey
4. Records 4.1 Follow up records Follow up records are kept in the audit year The percentage of T2DM patients whose follow up records are kept in the audit year EHR
4.2 Annual management summary report Annual management summary report, including summary of management status and comprehensive physical examination report are kept in the audit year The percentage of T2DM patients whose annual management summary reports are kept in the audit year EHR
5. Health status 5.1 Blood glucose target The patient’s latest fasting blood glucose is between 4.4–7.0 mmol/L; and post prandial blood glucose < 10.0 mmol/L in the audit year The percentage of T2DM patients whose latest blood glucose is under control in the audit year based on the following criteria:
Fasting blood glucose is between 4.4–7.0 mmol/L;
Post prandial blood glucose < 10.0 mmol/L.
EHR
5.2 HbA1c target The patient’s latest HbA1c < 7%; or HbA1c < 8% (for patient with severe hypoglycemia or age ≥ 80 or micro or macro vascular complications) in the audit year The percentage of T2DM patients whose latest HbA1c is under control in the audit year based on the following criteria:
HbA1c < 7%; or HbA1c < 8% (for patients with severe hypoglycemia or age ≥ 80 or micro or macro vascular complications).
EHR
5.3 BP target The patient’s latest BP < 130/80 mmHg;
or BP < 140/90 mmHg for old patient or patient with CHD in the audit year
The percentage of T2DM patients whose latest BP is under control in the audit year based on the following criteria:
BP < 130/80 mmHg;
or < 140/90 for old patient or patient with CHD
EHR
5.4 Blood lipid target The patient’s latest LDL-C < 1.8 mmol/L (for patient with ASCVD); or LDL-C < 2.6 mmol/L (for patient without ASCVD) in the audit year The percentage of T2DM patients whose latest LDL-C is under control in the audit year based on the following criteria:
LDL-C < 1.8 mmol/L (with ASCVD);
or LDL-C < 2.6 mmol/L (without ASCVD).
EHR
5.5 BMI target The patient’s latest BMI < 24 kg/m2 in the audit year The percentage of T2DM patients whose latest BMI < 24 kg/m2 in the audit year EHR
5.6 Hypoglycemia episodes The patient’s episodes of hypoglycemia (including symptomatic hypoglycemia and test results) in the most recent month during the audit year The percentage of T2DM patients who experienced episodes of hypoglycemia (including symptomatic hypoglycemia and test results) in the most recent month during the audit year Patient survey
5.7 T2DM related admissions to hospital The patient’s T2DM related admissions to hospital in the audit year The percentage of T2DM patients who experienced T2DM related admissions to hospital in the audit year Patient survey
6. Patient satisfaction 6.1 Satisfaction with treatment The patient’s perceived satisfaction with treatment Score of DTSQ from T2DM patients in the audit year Patient survey
6.2 Satisfaction with communication The patient’s perceived satisfaction with communication Score of communication satisfaction from T2DM patients in the audit year Patient survey
7. Self-management 7.1 Knowledge of self-management The patient’s knowledge of self-management Score of MDKT from T2DM patients in the audit year Patient survey
7.2 Adherence to medication The patient’s adherence to medication Score of Morisky 8 Item Scale from T2DM patients in the audit year Patient survey
7.3 Adherence to healthy behavior The patient’s adherence to healthy behavior Score of SDSCA from T2DM patients in the audit year Patient survey
  1. Abbreviations: GP General practitioner; T2DM Type 2 diabetes mellitus; EHR Electronic health record; HbA1c Glycosylated hemoglobin; BP Blood pressure; TC Total cholesterol; TG Triglyceride; LDL-C Low density lipoprotein cholesterol; HDL-C High density lipoprotein cholesterol; BMI Body mass index; ECG Electrocardiogram; CHD Coronary heart disease; ASCVD Arteriosclerotic cardiovascular disease; DTSQ Diabetes Treatment Satisfaction Questionnaire; MDKT Michigan Diabetes Knowledge Test; SDSCA Summary of Diabetes Self-Care Activities Measure